[PRAGMATIC TURN IN HEALTHCARE ETHICS: CHALLENGES AND OPPORTUNITIES FOR TRAINING]. / LE TOURNANT PRAGMATIQUE DE L'ÉTHIQUE EN SANTÉ: ENJEUX ET PERSPECTIVES POUR LA FORMATION.

The complexity of health care practices has given rise to a new need for ethics. Ethics is indeed less mobilized to produce a moral discourse on practices, then as a resource for action, a skill, for the development, by the actors, of autonomous, responsible and critical acting. This pragmatic approach to ethics requires changes in teaching practices, in a more experiential, reflexive and situational perspective. However, an epistemological rereading of the notion of competence will lead us to question its use in ethics. Just focusing on the capacity of actors to re-mobilize predetermined resources of action does not guarantee the effective capacity of the actors to initiate a new situated action, according to the singularity of the context. This text will propose to go beyond an ethical competence approach, revisiting the latter through the prism of capacitation. In this context, the educational line of sight of ethics is no longer "knowing how to do ", but developping "power to do".

[Chapter 4. Care, capabilities and disability: what ethics for an inclusive society]. / Chapitre 4. Care, capacité et handicap?: quelle éthique pour une société inclusive?

The purpose of this contribution is to show the way in which confronting theories of justice and democracy with the question of disability constrains the former to reconsider their contractarian groundings and to build up a frame that takes into account the effective situation of the most vulnerable persons. In this perspective, the approach through capabilities, while it does appear as an advance in the taking into considerations the situation of these persons and their specific capacity, requires nevertheless a futher radicalization of this consideration and analysis, as well as, the construction of an ethical and political framework that could take account of the required conditions for an effective participation of the disabled persons in the definition of their individual and collective project.

Activity confrontation methods: A reflexive and metacognitive approach for interprofessional collaboration training.

Integration of interprofessional collaboration into healthcare education and training programmes has become a fundamental issue. Its objective is to learn how to collectively build collaborative care practice that addresses the uniqueness of each context and the specific situation of the patient. It is also about understanding the process of collectively building collaborative care practice in order to be able to apply it in different contexts. This article describes a study that aimed to examine the value of relying on activity confrontation methods to develop training. These methods consist of filming practitioners during an activity and encouraging them to analyse it. It was found that these methods encourage reflexive analysis of the motives for pursuing interprofessional action (identifying constitutive factors) but also a metacognitive approach on the conditions of learning (p < 0.01). In addition to the educational dimensions (methods and leadership positions) and organisational dimensions (frameworks), it was found that the patient's role is essential in developing interprofessional care practice and training (p < 0.01). Given the nature of these findings, this article goes on to suggest that the patient must be considered a "partner" in development and delivery of interprofessional learning and care.

[Towards a reflexive governance of the ethical approach in healthcare institutions]. / Vers une gouvernance réflexive de la démarche éthique dans les institutions de soins.

We stand up in this article for bioethics as practice, as attest since the 1980 the evolution of theoretical work in bioethics towards a growing need of contextualization. This development justifies for us to work out a context sensitive, pragmatist and reflective ethics as a learning process. Such an idea of ethics allows to understand the transition from hospital ethics committes and clinical ethics consultation towards a more integrative institutional perspective that we defend here. This institutionalization of clinical ethics support services has to be accompanied by a reflective governance of this process. The papers of this issue aim to take into account in a various way this evolution of the bioethical field, both practical, methodological, institutional, educational and theoretical.

[How to institutionalize the ethical approach. The example of geriatric care]. / Quelle institutionalisation de la démarche éthique? L'exemple des soins gériatriques.

This paper aims at showing how strengthening and adapting the system of care to the needs and expectations of older people today requires a change in the way to conceive the ethical approach. If clinical ethics remains a fundamental tool of the ethical approach in order to identify and to understand the ethical issues of a geriatric practice both complex and uncertain, as well as to adequately articulate the patient's expectations, the technical quality of care and the organization of a complex support, this area of care manifests the need for an institutionalization of the ethical approach. To be relevant, legitimate and effective, the ethical approach must not only be opened to the organizational aspects of care but also be able to fit into the institutional dynamics.

[From using a model of decisional clinical ethics to constituting a place for collective learning. The experience of a reflexive seminar between healthcare professionals and ethics researchers]. / De l'usage d'une grille d'éthique clinique décisionnelle à la constitution d'un lieu d'apprentissage collectif. L'expérience d'un séminaire réflexif entre professionnels de santé et chercheurs en éthique.

This paper shows how an experimental clinical ethics device, proposed by researchers in ethics to intensive care units professionals, has created a collective learning context. The outcome of such a collective learning has been the progressive working-out, from the clinical and care practice, of a given clinical ethics grid into a more intensive care units context adapted grid. Some comments are made about the importance to subjectivize a clinical ethics approach, about the collective learning device installed throughout the joint health care professionals--researchers in ethics seminar and about the need to institutionalize ethics.

[First analysis of the deployment of the ethical approach in the field of mental health in the Nord Pas-de-Calais region]. / Première analyse du déploiement de la démarche éthique dans le champ de la santé mentale en région Nord Pas-de-Calais.

For 3 years, the Regional Federation of Mental Health Research (F2RSM) has led a space ethics reflexion Department of mental health (ERESM) to federate structures that ethical institutions and mental health services have been creating in the Nord-Pas de Calais. This approach is, in many ways, revealing issues that involve the institutionalisation of ethical reflection in care facilities. In this article, after referring to the major developments in this field, we describe the conditions for the emergence of ethical bodies in the region. Through the choice of development and operation of the ethical reflexion department, we highlight a number of points of attention that illustrate the complex articulation between institutional expectations and concerns of professionals. The trajectory of the ERESM is thus revealed as a process of reflective learning open to all stakeholders, providers and users of mental health.

[From the pragmatic to pragmatism: what are the stakes for training in ethics?]. / Du pragmatique au pragmatisme : quels enjeux pour la formation à l'éthique?

The contemporary evolution of the request and the recourse for ethics in the health field questions the models of ethics training. Indeed the stake is no more to train actors able of producing a moral speech on the practices but, in a destabilized context, to accompany them in the development of new practices in professional situation. This pragmatic turn in health ethics requires more active, reflective and contextual models of training, needing new links between training places and care practices. This paper is about theoretical foundations of such an ethics pedagogy, and about its stakes in terms of re-institutionalization. Pragmatism, and more particularly the approach of John Dewey, will be mobilized here to found educational practices needed by such an ethics pedagogy (an experiential, reflective and collective learning), but also to consider issues concerning training device linked to such a learning. On this point, the philosophy of integrative block-release training is investigated as a way to develop future professional competences, even if the last part of this text will insist on the reflective governance such an alternation requires and on the "re-institutionalization of the ethics pedagogy" that the latter generates.

Institutional challenges for clinical ethics committees.

Clinical ethics committees (CECs) have been developing in many countries since the 1980s, more recently in the transitional countries in Eastern Europe. With their increasing profile they are now faced with a range of questions and challenges regarding their position within the health care organizations in which they are situated: Should CECs be independent bodies with a critical role towards institutional management, or should they be an integral part of the hospital organization? In this paper, we discuss the organizational context in which CECs function in Europe focusing on five aspects. We conclude that in Europe clinical ethics committees need to maintain a critical independence while generating acceptance of the CEC and its potential benefit to both individuals and the organization. CECs, perhaps particularly in transitional countries, must counter the charge of "alibi ethics". CECs must define their contribution to in-house quality management in their respective health care organization, clarifying how ethical reflection on various levels serves the hospital and patient care in general. This last challenge is made more difficult by lack of consensus about appropriate quality outcomes for CECs internationally. These are daunting challenges, but the fact that CECs continue to develop suggests that we should make the effort to overcome them. We believe there is a need for further research that specifically addresses some of the institutional challenges facing CECs.

France: a focus on the new reproduction.

KIE: This bibliographic essay's initial focus is on publications reflecting European concern with the ethical implications of reproductive technologies. Titles by P. Verspieren, the Institut Catholique de Lyon, C. Lefèvre, E. Loumaye and J-F. Malherbe, and J-L. Baudouin and C. Labrusse-Riou are briefly discussed. Also mentioned are recently published works on biomedical technologies by B. Edelman, M-A. Hermite, Labrusse-Riou, and M. Remond-Gouilloud; on the social impact of science by G. Hottois, J. DeVooght, R. Rasmont, and P. Van Gansen; on medical ethics by C. Ambroselli, and by Malherbe; on AIDS by E. Hirsch, by E. Conan, and by Malherbe and S. Zorrilla. All cited titles are in French.^ieng